question

Who first conclusively demonstrated the clinical use of ether in a surgical setting and where? *

answer

-William T.G. Morton, a dentist, used ether at Massachusetts General Hospital on Oct. 16, 1846 in the ether dome. - Tried to patent ether but too many others assuming credit. -Lived in poverty died of a seizure.

question

Who is credited with introducing cleanliness, good ventilation and adequate nurtition in hospitals during the Crimean War?*

answer

Florence Nightengale "Hospitals don't have to be pest houses"

question

What two physicians hypothesized that infection spread by the health care provider was the main cause of pueperal fever, and reccomended hand washing?

answer

Oliver Wendell Holmes & Ignaz Phillip Semmelweis (Semmelweis noticed mid-wives infection rates were lower than medical students and that mid-wives washed their hands between patients.)

question

When did the germ theory become widely accepted?

answer

1880's

question

Occasional Anesthestists

answer

Physicians did not frequently choose to go into anesthesia due to poor pay. Anesthesia was provided poorly, morbidity & mortality were high. In the 1890's Europe & the US recognized a need for devoted anesthesia professionals. England chose a physician model, the US did not choose. Surgeons began to encourage nurses at the Catholic Hospital Sisters to train as nurse anesthetists.

question

Beginnings of Nurse Anesthesia

answer

Civil War Franco-Prussian War The need for health care created by wars led to use of nurses as anesthetists in the US.

question

First Nurse Anesthetists

answer

Sisters of St. Joseph Franscisican Sisters at St. John's trained and sent out several nurse anesthetists.

question

St. Mary's

answer

-Edith & Dinah Graham became anesthetists under direction of Charles Mayo. Alice Magraw took over Dinah Graham's position as anesthetist. -Magraw implemented record keeping and published findings making anesthesia safer. Magraw is known as "Mother of Anesthesia". The country began adopting nurses as anesthetists and hospitals and surgeons began employing them.

question

Agatha Hodgins*

answer

Canadian nurse Dr. George Crile's nurse anesthetist Founder of the AANA Lakeside Hospital Trained nurses in France during the war. Pioneered early anesthsia machines and nitrous and oxygen use. First president of NANA

question

Anne Penland

answer

Nurse with Presbyterian Hospital Base 2 Went to British front British were impressed, began training their own nurse anesthetists

question

Before WW1 what four formalized nurse anesthesia programs opened?

answer

St. Vincent's- Portland OR (1909) St. John's- Springfield IL (1912) New York Post Graduate Hospital- NYC (1912) Long Island College Hospital- Brooklyn (1914)

question

Francis Hoeffer

answer

Stated that nurse ansethesia was illegal as they were practicing medicine. Crile (from Lakeside) challenged Ohio legislature and 1919 amendment stated nurses could practice under supervision of a physician.

question

Dagmar Nelson

answer

Charged with practicing medicine in California court. Court decided in favor of Nelson.

question

WW2 & Nurse Anesthetists

answer

AANA began certification exam US trained 2000 nurse anesthetists Nurse anesthetists outnumbered anesthesiologists 17:1

question

American Society of Anesthesiologists

answer

Founded in 1936 Changed anesthetist to anesthesiologist and stated it wanted to eliminate nurse anesthetists and make anesthesia an all physician practice. Made working with anesthetists or training them unethical... Stated campaign against nurse anesthetists, AMA, American College of Surgeons & American Hospital Association came to CRNA's defense.

question

Beecher & Todd

answer

Followed over 600,000 anesthetic procedures and found the following mortality rates. Anesthesiologists: 1:890 Nurse Anesthetists: 1:1800

question

Edward L.T. Lyon

answer

First US Army male anesthetist Proposed bills which allowed males to be nurses in the army in April 1966.

question

The 1960's and Nurse Anesthesia

answer

Medicaid & Medicare introduced Anesthesiologists met, did not include anesthetists Not enough anesthesia providers Nursing as a profession ASA & AANA began working together, ASA withdrew statement of support... Recognized need for bachelor's program as prerequisite and academic move from hospitals Some states attempted to expand their scope of practice for CRNA's Codification in legislative bills

question

AANA & Federal Involvement in 1970's

answer

Acquired DC lobbyist ASA started study that asked for CRNA's addresses, places of work. Stated it was in cooperation with AANA and need for anesthesiologists to be more involved with credentialing for nurse anesthetists. Set into motion higher standard of education for CRNA's and Council for Higher Education Accreditation. 2 Anesthesiologist Assistant programs opened in 1974 about 1,000 practice today.

question

TEFRA Tax Equity & Fiscal Responsibility Act of 1982

answer

Effort to contain hospital costs Anesthesiologists billing for services when not present or performed.

question

Health Care Financing Administration

answer

HCFA came up with 7 standards for anesthesiologist reimbursement. 1- perform pre-anesthesia evaluation 2- prescribe the anesthesia plan 3- personally participate in induction & emergence 4- Monitor anesthesia at frequent intervals 5- Remain physically available 6- Provide needed postanesthesia care 7- Refrain from personally performing anesthetic procedure when purporting to be engaged in medical direction REQUIRED PHYSICIAN SUPERVISION under Medicare reimbursements

question

Hyde vs. Jefferson Parish Hospital

answer

Based on whether an exclusive contract for anesthesiologist was violating Sherman anti-trust laws. Derogatory statements against CRNA's, alerted AANA to the need to revitalize its public relations program and watch for attempts to discredit the profession.

question

Medicare Payment System for Hospital Services

answer

Prospective Payment System (PPS) introduced diagnostic related groups (DRG) as form of payment. AANA proposed & acquired: 1- temporary pass through of hospitals CRNA costs 2- single exception to the unbundling provisions questionable if anesthesiologists would be reimbursed for CRNA services 3- direct reimbursement for all CRNAs under Medicare Omnibus Budget Reconciliation Act: Direct reimbursement of CRNA's enacted into law. Two payment schedules: 1) with anesthesiologist 2) independent

question

Quality of Care Studies

answer

US House of Representatives studied VA. W.H. Forrest, Anesthesiologist, Stanford Center for Health Care research, looked at primarily CRNA and primarily anesthesiologist hospitals. Both studies found NO DIFFERENCE in anesthesia outcomes based on provider.

question

ASA Anesthesia Care Team (ACT) Statement

answer

Implies CRNA's are technicians AANA does not agree, restrictive of practice, inhibits productivity of providers and is wasteful of anesthesia personnel.

question

Surgeon liability for CRNA action

answer

Only under 2 circumstances: 1- surgeon dictates what CRNA does (e.g. regional vs. GA) 2- hospital policies mandate a degree of supervision "Captain of the Ship" null and void

question

Study by Pine, Holt & Yu

answer

Medicare data from over 400,000 patients in 22 states found that patients were equally safe under CRNA, anesthesiologist, or ACT.

question

When was the AANA founded?

answer

1931 AANA has more than 36,000 members, more than 90% of CRNA's are members. It establishes guidelines for nurse anesthesia practice.

question

What are the three requirements to become a CRNA?

answer

1- unrestricted RN license 2- COA accredited program graduate 3- pass CCNA boards

question

Scope of Practice for CRNA's

answer

1- Performing & documenting a preanesthetic assessment and evaluation of the patient, including requesting consultations and diagnostic studies; selecting, obtaining, ordering, and administering preanesthetic medications & fluids; and obtaining informed consent for anesthesia. ASSESS, LABS, MEDS & CONSENT

question

Task 2

answer

Developing & implementing an anesthetic plan. CARE PLAN

question

Task 3

answer

Initiating the anesthesia technique, which may include general, regional & local anesthesia & sedation. METHOD of ANESTHESIA DELIVERY

question

Task 4

answer

Selecting, applying & inserting appropriate noninvasive and invasive monitoring modalities for continuous evaluation of the patient's physical status. MONITOR VS

question

Task 5

answer

Selecting, obtaining & administering the anesthetics, adjuvant and accessory drugs, and fluids necessary to manage the anesthetics. GIVE 'EM DRUGS

question

Task 6

answer

Managing a patient's airway and pulmonary status using current practice modalities. PULSE OX & ETCO2

question

Task 7

answer

Facilitating emergence and recovery from anesthesia by selecting, obtaining, ordering, and administering medications, fluid, and ventilatory support. RECOVERY

question

Task 8

answer

Discharging the patient from a postanesthesia care area and providing postanesthesia follow up and care. DISCHARGE

question

Task 9

answer

Implementing acute and chronic pain management modalities. MANAGE PAIN

question

Task 10

answer

Responding to emergency situations by providing airway management, administration of emergency fluids and drugs, and using basic or advanced cardiac life-support techniques. EMERGENCY MANAGEMENT

question

Tasks 1-10 Scope of Practice

answer

1-Assess, labs, meds and consent 2- Care plan 3-Method of Anesthesia delivery 4- Monitor VS 5- Give drugs 6- Pulse ox & ETCO2 7- Recovery 8- Discharge 9- Manage pain 10- Emergency management

question

Council of Accreditation of Nurse Anesthesia Educational Programs (COA)

answer

Accreditation of Educational Programs Educational Standards including didactic curriculum Implemented monitoring of pass rates

question

Certification of Nurse Anesthetists (CCNA)

answer

Certification of CRNA's Requirements, guidelines & prerequisites for certification Exam eligibility Grants initial certification

question

Council on Recertification of Nurse Anesthetists (COR)

answer

Evaluation & recertification of CRNA's Formulate, adopt & evaluate eligibility criteria for recertification.

question

Council for Public Interest in Anesthesia (CPIA)

answer

Composed of anesthesia providers & representatives of the public concerned with issues that involve public safety in anesthesia care. Monitor social and health care trends and issues from viewpoint of public.

question

International Federation of Nurse Anesthetists (IFNA)

answer

International members, more than 50,000 members worldwide. Standards for education, practice, monitoring and a code of ethics.

question

AANA Vision Statement

answer

Vision Statement: recognized leaders in anesthesia care

question

AANA Mission Statement

answer

Mission Statement: Advancing patient safety and excellence in anesthesia.

question

AANA Core Values

answer

Core Values: Integrity, professionalism, advocacy & quality

question

AANA Motto

answer

Motto: Supporting our members- protecting our patients.

question

Helen Lamb

answer

Founder Barnes school of Anesthesia Developed initial method for approving schools which led to method of accreditation.

question

1945 Essentials of an Acceptable School for Graduate Registered Nurses

answer

Developed proper training programs and standard curriculum in response to poor programs in the US in preparation of WW2.

question

Bolton Act of 1943

answer

Offered financing of graduate nurses through established civilian schools of anesthesia.

question

How many anesthetics must be performed to meet COA standards?

answer

550 The average student performs 800 anesthetics.

question

Joseph Priestly*

answer

1772-1774 Leeds, England Nitrous oxide for recreational use Discovered oxygen & nitrous oxide

question

Horace Wells*

answer

-1844 -Dentist -Social use of nitrous -No credit (suicide)

question

1840's Ether Frolics Crawford Long*

answer

- Ether frolics & small cyst removal - Injured themselves in frolics and couldn't recall - Died in an insane asylum

question

James Young Stimpson*

answer

-England - Gave chloroform to Queen Victoria during childbirth in 1853 & 1857

question

Anesthesia Problems

answer

-Main surgical problem was infection - Main anesthesia problem was unskilled or "occasional anesthetist" -Limited prestige, low pay

question

Who were some of the first anesthetists in the US?

answer

Mrs. Harris & Catherine Lawrence* Used chloroform and stimulants at the Battle of Gettysburg during the Civil War Sister Mary Bernard*: "first anesthetist" in the US

question

Who was Carl Koller?*

answer

- Ophthalmologist who used topical cocaine for anesthesia of the eye

question

Who was August Bier?*

answer

-Gave the first spinal anesthetic in 1898, 3ml of .5% cocaine IT. -Bier Block in 1908

question

Who is Charles Mayo?*

answer

- Opened the Mayo clinic with nurse anesthesia instruction - Role in the UN, appointed by Eisenhower -Died in MVA on his 70th birthday

question

Who is John Snow?*

answer

-First anesthesiologist or "physician anesthetist" - Died from stroke at 45, after spending his last years conducting experiments on himself.

question

Who is known as the "Mother of Anesthesia"?*

answer

-Training program in 1900's - Alice Magraw -14,000 anesthetics without a death - Late 1800's to early 1900's

question

1990's

answer

-1996 Anesthesiologist outnumber CRNA 1.2:1 -55% of anesthesiology residents were international medical graduates

question

2000's

answer

-2007: 38,000 CRNAs in the US -40% of practicing CRNAs have been practicing for more than 20 years. - SRNA graduates number 800/year in 2000 (84 schools) - 1,100 CRNAs on active duty in the military

question

2013

answer

-2,200 graduates/year (118 schools) -40,000 CRNA's -Median salary $150,000, starting usually $110-130K

question

ASA I

answer

Patients are considered to be normal and healthy. Patients are able to walk up one flight of stairs or two level city blocks without distress. Little or no anxiety. Little or no risk. This classification represents a "green flag" for treatment.

question

ASA II

answer

Patients have mild to moderate systemic disease or are healthy ASA I patients who demonstrate a more extreme anxiety and fear toward dentistry. Patients are able to walk up one flight of stairs or two level city blocks, but will have to stop after completion of the exercise because of distress. Minimal risk during treatment. This classification represents a "yellow flag" for treatment. Examples: History of well-controlled disease states including non-insulin dependent diabetes, prehypertension, epilepsy, asthma, or thyroid conditions, smoker, overweight; ASA I with a respiratory condition, pregnancy, and/or active allergies. May need medical consultation. Note: Patients who demonstrate a more extreme anxiety and fear toward dentistry have a baseline of ASA II even before their medical history is considered; that situation raises the classification system

question

ASA III

answer

Patients have severe systemic disease that limits activity, but is not incapacitating. Patients are able to walk up one flight of stairs or two level city blocks, but will have to stop enroute because of distress. If dental care is indicated, stress reduction protocol and other treatment modifications are indicated. This classification represents a "yellow flag" for treatment. Examples: History of angina pectoris, myocardial infarction, or cerebrovascular accident, congestive heart failure over six months ago, slight chronic obstructive pulmonary disease, and controlled insulin dependent diabetes or hypertension. Will need medical consultation.

question

ASA IV

answer

Patients have severe systemic disease that limits activity and is a constant threat to life. Patients are unable to walk up one flight of stairs or two level city blocks. Distress is present even at rest. Patients pose significant risk since patients in this category have a severe medical problem of greater importance to the patient than the planned dental treatment. Whenever possible, elective dental care should be postponed until such time as the patient's medical condition has improved to at least an ASA III classification. This classification represents a "red flag" ‑ a warning flag indicating that the risk involved in treating the patient is too great to allow elective care to proceed. Examples: History of unstable angina pectoris, myocardial infarction or cerebrovascular accident within the last six months, severe congestive heart failure, moderate to severe chronic obstructive pulmonary disease, and uncontrolled diabetes, hypertension, epilepsy, or thyroid condition. If emergency treatment is needed, medical consultation is indicated

question

ASA V

answer

Patients are moribund and are not expected to survive more than 24 hours with or without an operation. These patients are almost always hospitalized, terminally ill patients. Elective dental treatment is definitely contraindicated; however, emergency care, in the realm of palliative treatment may be necessary. This classification represents a "red flag" for dental care and any care is done in a hospital situation.

question

ASA VI

answer

Clinically dead patients being maintained for harvesting of organs.

question

ASA-E

answer

Emergency operation of any variety (used to modify one of the above classifications, i.e., ASA III-E).

question

Appendectomy

answer

GA-OETT Supine Inpatient 30mins

question

Arm Fracture

answer

GA-OETT, LMA or MAC Regional Block: brachial Supine Out patient 45 mins-6h

question

BMT (bilateral myringotomy) /PE (pressure equalization) Tubes

answer

Mask Supine Outpatient 5 minutes

question

Breast Biopsy

answer

MAC supine 10-30 minutes

question

Broken Jaw

answer

GA-Nasal intubation or fiberoptic intubation protocol Supine Inpatient 1-3 hours

question

BTL p CS (Bilateral tubal ligation after cesarean section)

answer

SAB or epidural Steep trendelenberg, supine, lithotomy Inpatient 15-25 mins

question

Bunion repair

answer

MAC Supine Outpatient 30 minutes

question

CABG

answer

GA-OETT Supine Inpatient 3-4 hours

question

Cardioversion

answer

MAC Supine Outpatient <30 minutes

question

Carotid Endarectomy

answer

GA-OETT, MAC Supine Inpatient 1-2 hours

question

Carpal Tunnel Release

answer

MAC Bier block, axillary or brachial Supine Home 30-90 minutes

question

Cataracts

answer

MAC Retrobulb-peribulbular block Supine Outpatient 15-60 minutes

question

C-section

answer

GA-OETT, SAB, epidural Supine with left lateral tilt Inpatient 20-90 minutes

question

Craniotomy

answer

GA or MAC Supine, sitting, lateral or prone Inpatient 3-5 hours

question

Colon Resection

answer

GA-OETT, epidural Supine, modified lithotomy Inpatient 1-3 hours

question

Colporrhaphy (bladder repair)

answer

GA-OETT, LMA* Lithotomy In or outpatient 1-4 hours

question

Electroconvulsive Therapy (ECT)

answer

MAC Supine Outpatient <10 minutes

question

Endometriosis Ablation (Laparascopic)

answer

GA-OETT Dorsal lithotomy, stirrups or steep trendelenberg Outpatient or 1 day admit 45 mins- 4 hours

question

Hemorrhoidectomy

answer

GA-OETT, MAC, SAB Prone, lateral decubitus, lithotomy, jack-knife Outpatient 10-90 minutes

question

Hip Fracture

answer

GA-OETT, SAB or epidural Supine, left decubitus Inpatient 3-6 hours

question

Hysterectomy

answer

GA-OETT, LMA, spinal or epidural Supine, lithotomy Inpatient 45 mins- 2 hours

question

Inguinal Hernia

answer

GA-OETT, LMA, MAC, SAB Supine In or Outpatient 3 hours

question

Knee Scope

answer

GA-OETT, LMA, SAB, regional Supine Outpatient 2 hours

question

Laporascopic BTL

answer

GA-OETT Supine, lithotomy Outpatient 20-35 minutes

question

Mastectomy

answer

GA-OETT, LMA, regional Supine Inpatient 1-3 hours

question

Microdiscectomy

answer

GA-OETT Prone, kneeling Inpatient (24 hours) 1-2 hours

question

MRI of Brain/Neck

answer

GA-OETT, LMA, MAC Supine Outpatient ≥ 1 hour

question

Nissan Fundoplication

answer

GA-OETT (GERD=no LMA) Supine Inpatient 1-2 hours

question

Oral Surgery

answer

GA-OETT Supine Out or inpatient ½-3 hours

question

Prostate Biopsy

answer

MAC Supine Outpatient 15 minutes

question

Prostate Resection

answer

GA-OETT, LMA, SAB or epidural Lithotomy Inpatient 1-2 hours

question

Rotator Cuff Repair (RCR)

answer

GA-OETT, regional Lateral decubitus, beach chair Outpatient 1-4 hours

question

Sinus Surgery

answer

GA-OETT, MAC, HOB 30° or supine Outpatient 1-4 hours

question

Thoracoscopy

answer

GA-OETT (double lumen tube), thoracic epidural Lateral Inpatient ½-1½ hours

question

Thyroidectomy

answer

GA-OETT Supine 24 hours inpatient 1-2 hours

question

Tonsillectomy

answer

GA- nasal ETT Supine Outpatient 10-60 minutes

question

Vaginal Delivery

answer

SAB, epidural Lithotomy Inpatient Time varies

question

Thoracotomy

answer

GA-OETT, thoracic epidural Lateral Inpatient 1-3 hours

question

Pre-op anesthetic

answer

Interview Review of Systems Review labs EKG Old charts Discuss prior experiences with patient/family, discuss options, benefits & risks. CRNA's can order any lab test or medication that is pertinent to the anesthetic. EG: pain meds, EKG, anti-emetic, labs *Include caveat that GA may be required.

question

Intra-op anesthetic

answer

Do what you said you would. Have back-up plans, be vigilant. Expect the worst, hope for the best. Be prepared for the unexpected.

question

Post-op anesthetic

answer

PONV Pain control Morbidity (cut lips, damaged teeth, sore neck, limbs, nerve damage, sore throat, scratched eyes etc.) Exit interview a few days later.

question

Which factors affect the absorption of inhalational anesthetics?

answer

CO, respiratory rate

question

Advantages of Local Anesthetic

answer

- Don't have the risks involved with GA - If they come to OR it is monitored anesthesia care

question

Disadvantages of Local Anesthetic

answer

-Physician can do independent of CRNA, "straight local"

question

Advantages of MAC

answer

-Light to moderate to deep sedation similar to general - May need oral airway -Spinal, epidural or regional

question

Disadvantages of MAC

answer

- Sometimes people are uncomfortable so they require GA anyway.

question

Advantages of GA

answer

-A progressive depression of the CNS -Controlled passage through stage 1 and 2 to arrive in stage 3. - Patient cooperation not absolutely essential - Unconscious -Amnesia - Rapid onset of action - Titration possible

question

Disadvantages of GA

answer

-Loss of protective airway reflexes - Depression of VS - Advanced training required - Additional personnel required - Special Equipment/setting -Need recovery room - Greater risk of intra-op complications -Post-anesthetic complications -More extensive pre-op evaluation, including lab work Indications: extreme anxiety or fear, mentally/physically disabled adults or children, poor patient cooperation, infants & children, traumatic procedures Contraindications: lack of adequate training by doctor or personnel, lack of equipment, facilities or medically compromised patient

question

Mask

answer

-Oral airway or nasal airway -Nasal avoided, bleeding -Short-term case

question

LMA

answer

Most common airway manipulation -Must be spontaneously breathing - LMA at induction, ventilate until propofol wears off -Reflux not a candidate

question

ETT

answer

OETT: oral endotracheal tube NETT: nasal endotracheal tube DLT: double lumen tube (one lung ventilation- thoracic cases) Most secure airway.

question

Advantages of TIVA

answer

-Used with allergies to gas/MH history - Quick stages of anesthesia -TIVA is a general anesthetic -used for neuro cases (rapid awakening)

question

Advantages of Epidural/Neuraxial

answer

-Pain control 12-24 hours post surgery (duramorph) - no respiratory issues - Used with older or compromised patients

question

Disadvantages of Epidural/Neuraxial

answer

- Urinary retention - Immobile, pad immobile extremities

question

Advantages of Regional Block

answer

- Somewhat awake, will hear things - MAC cases

question

Disadvantages of Regional Block

answer

- Need to be asleep with tourniquet because it is uncomfortable - Patient can remain awake

question

Interscalene

answer

Indications for interscalene nerve block include the following: Shoulder surgery, such as rotator cuff repair, acromioplasty, hemiarthroplasty, and total shoulder replacement Humerus fracture Other arm surgery that does not involve the medial aspect of the forearm or hand

question

Femoral

answer

Indications: Anterior thigh and knee surgery Landmarks: Femoral (inguinal) crease, femoral artery pulse Nerve Stimulation: Twitch of the patella (quadriceps) at 0.2-0.5 mA current Local anesthetic: 20 mL Complexity level: Basic

question

Bier Block

answer

Indications: Surgery on the wrist, hand and fingers. Local anesthetic: 15 mL of 2% lidocaine (up to 40ml) Complexity level: Basic

question

Malignant Hyperthermia Cause

answer

-Open ryanodine receptor allows continuous release of calcium from the sarcoplasmic reticulum. -Triggers: all anesthetic gases -Nitrous is safe.

question

MH S/S and treatment

answer

Trigger: all halogenated anesthetics and succinylcholine (nitrous is safe) Increasing CO2, hyperthermia Treat: dantrolene 2.5 mg/kg every 5 minutes up to 10mg/kg Anesthetic plan: MAC, regional, TIVA (for general) Flush machine, new absorber, new circuit

question

Stages of Anesthesia: Stage 1

answer

Stage 1: Analgesia Stage 2: Delerium Stage 3: Surgical Anesthesia Stage 4: Overdose (medullary paralysis) Stage 1: -Beginning of induction drug to loss of consciousness -dizzy, loses sense of reality -lessened sensitivity to touch and pain -hearing is increased, response to noise intensified

question

Stage 2

answer

Delirium or excitement phase: loss of consciousness to onset of rhythmicity of VS into entry of surgical anesthesia -Struggling, ↑ muscle tone, jaw sets, eyelids closed, may breath hold and retch , nystagmus -Reflexes are hyperactive -Respiratory pattern is irregular -"Goofy" disconjugate eyes - NEVER EXTUBATE (laryngospam)

question

Stage 3

answer

Surgical or Operative Stage: -End of stage 2 to cessation of respirations - Respirations regular, patient likely intubated or LMA There are 4 planes of anesthesia in Stage 3. -Most surgical procedures occur in plane 2.

question

Stage 4

answer

Death... cessation of respiration to death, respiratory and circulatory arrest. Circulatory collapse. -all reflexes absent - flaccid paralysis - marked hypotension - weak irregular pulse

question

IV anesthetics & pregnancy

answer

-Most are safe - Versed avoided but may be ok -Fentanyl & propofol frequently used

question

Inhalational Anesthetics & pregnancy

answer

All gas anesthetics: -depress the uterus, ↑ risk of miscarriage - may increase blood loss during intrauterine procedures - reduced MAC required due to higher circulating blood volume hemodilution

question

Benefit of continuous infusion of opioids

answer

-Used for maintenance of general anesthesia -Balanced technique -Morphine, fentanyl, alfentanil, sufentanil, remifentanil, demerol

question

Which factors lower MAC requirements?

answer

↑ age Hypothermia Depressant medications α₂ agonists Acute ethanol consumption Metabolic acidosis Hypoxemia Anemia Hypotension Hyponatremia Pregnancy N₂O, ketamine, lidocaine, clonidine, lithium

question

Which factors raise MAC requirements?

answer

Kids (higher metabolism/RR) Hyperthermia Hyperthyroidism Hypernatremia Chronic alcohol consumption MAO Inhibitors Cocaine, levodopa

question

What is the mechanism of action of local anesthetics?

answer

- Block Na channels preventing depolarization of the cells.

question

Which medications reverses narcotics?

answer

- Narcan .04-4mg IV q 3 minutes

question

Which medications reverses benzodiazepines?

answer

- Flumazenil -Competitive agonist at receptor binding sites. Sole benzodiazepine antagonist. - 0.2 mg doses (2ml) titrated up gradually to desired LOC, up to 1mg

question

Which medications reverse paralytics?

answer

-Neostigmine .04-.07mg/kg up to 5mg (combine with robinul because neostigmine will increase salivation) - Endrophonium .5-1mg/kg (combine with atropine to block muscarinic cholinergic effects)

question

Desflurane Advantages & Disadvantages

answer

Advantages: quick, rapid uptake & elimination, minimal metabolism Disadvantages: pungent, respiratory irritant, expensive, tachycardia

question

Desflurane dosing & metabolism

answer

Dosing: 3-9% induction, 2-6% maintenance Metabolism: <0.1%

question

Isoflurane Advantages & Disadvantages

answer

Advantages:cheap, minimal metabolism Disadvantages: pungent, respiratory irritant, slow uptake & distribution, coronary steal

question

Isoflurane dosing & metabolism

answer

Dosing: 1-4% induction, .5-2% maintenance Metabolism: <1%

question

Sevoflurane Advantages & Disadvantages

answer

Advantages: not respiratory irritant, rapid uptake & distribution non-pungent Disadvantages: metabolized, compound A, expensive, ↑ fluoride ion concentration

question

Sevoflurane Dosing & Metabolism

answer

Dosing: 4-8% induction 1-4% maintenance Metabolism: 3-6% by liver

question

What are each anesthetic agents blood/gas solubility coeffcient? What does this number tell you?

answer

Des:0.42 Iso:1.4 Sevo: 0.6 N₂O: .47 SPEED -The proportion of the anesthetic that will be soluble in the blood. -The more soluble the drug, the slower the uptake. (The gas is "tied" up and unable to get to brain.) - Poorly soluble = rapid uptake

question

What are the MAC values of each anesthetic? What does this number mean?

answer

Des: 5.8 Iso: 1.15 Sevo: 2 N₂O: 105 DOSE

question

What are the oil/gas values of each anesthetic? What does this number mean?

answer

Des: 18.7 Iso: 99 Sevo: 50 N₂O: 105 POTENCY

question

What is the second gas effect?

answer

Simultaneous administration of a relatively slow agent, such as iso, and a faster agent, such as N₂O will speed the onset of the slower agent.

question

Nitrous Oxide Advantages & Disadvantages

answer

Advantages: moderate analgesia, rapid uptake & elimination, non pungent, does not ↓BP Disadvantages: expansion of closed air spaces, ↑PONV, immune supression, teratogenic, supports combustion, weak

question

Nitrous Oxide Dosing & Metabolism

answer

Dosing: 50-70% induction & maintenance Metabolism: <1%

question

Benzodiazepines

answer

-Versed- quick on and off .25 mg for elderly people, 1mg-2mg for most others

question

MAC of a Halogenated Anesthetic

answer

-The dose is expressed as minimum alveolar concentration necessary to produce anesthesia on surgical stimulation. -Faster the lung and therefore brain concentrations rise the faster the anesthesia is achieved.

question

MAC defined

answer

-MAC awake 1/3 (amnesia) -MAC bar 1.5 (block adrenergic receptors) usually goal for start of surgery -MAC intubation 2 (ETT, very stimulating)

question

Ventilation Effect

answer

The faster and more deeply a patient breathes or is ventilated the faster the patient loses consciousness and emerges. Ventilation/perfusion deficits or poor lung function hinders inhalation drug administration. Affects fast drugs the most.

question

Uptake into the Blood

answer

Vessel Rich: heart, liver, kidneys, brain, to a lesser degree muscle Vessel Poor: fat ↑ in CO slows uptake. Pediatric uptake is faster than adults (kids have higher alveolar ventilation per weight ratio).

question

Concentration Effect and Over-pressurizing

answer

-Concentration effect: A loading dose is given to speed initial uptake & turn up the flows ↑Fi% -"Over-pressurizing" is the process of significantly increasing a volatile anesthetic delivered to a patient to increase the alveolar concentration and therefore the amount dissolved in the blood, to speed uptake. Henry's Law

question

Diffusion hypoxia

answer

-Occurs during emergence - High concentrations of nitrous have been given - Nitrous is turned off - Nitrous exits the body quickly through the lungs and is replaced by nitrogen in the air - Results in transient dilution of oxygen and carbon dioxide - Administration of 100% FIO₂ for several minutes will prevent

question

Placement guidelines for Epidural

answer

-Intercristal/Tuffier's line - Feel iliac crest, guide placement of epidural - mark L3/L4 space, have patient arch back - "heavy" on solutions mean hyperbaric, goes down -Isobaric same as CSF, hypobaric lower than CSF -Marcain .5-.75% in dextrose commonly used

question

Which of the following correctly describes ketamine dose for IV induction? IM

answer

- 2-3 mg/kg IV for induction - 4-6 mg/kg IM Mixed with atropine to counteract salivation. -Maintenance: 15-45mcg/kg/min (1-3 mg/min)

question

What is the longest acting local anesthetic?

answer

- Tetracaine with epinephrine

question

What is a normal dibucaine number?

answer

-80, 80% of the PChE inhibited by dibucaine - Dibucaine Inhibition Test

question

ER, ORIF for finger reduction, ETOH

answer

- ETOH lowers MAC requirement with acute intoxication (already at .2-.3 MAC) - Chronic ETOH with raise MAC requirements (noticeable with propofol)

question

What causes bradycardia in kids?

answer

-Succinylcholine -Mix with atropine to counteract bradycardia

question

If eyes are midline which stage are they in?

answer

- Stage 1 or 3

question

During what stage do you NEVER extubate?

answer

Stage 2 -Delirium, prone to laryngospasm

question

Why are paralytics avoided in kids?

answer

- Want to maintain airway, respiratory drive - Succinylcholine causes MH, bradycardia - Use demerol and propofol for induction -Avoid reversals

question

What do narcotics do to pupils? Atropine?

answer

- Pinpoint: narcotics - Dilate: atropine

question

Stages of Anesthesia

answer

...

question

What medication can you use when a patient on ACE inhibitor is not responding to ephedrine or neosynephrine?

answer

- few units of vasopressin

question

Most adults use which size of MAC blade?

answer

3

question

Most adults use which size Miller blade?

answer

2 ( used ages 2+)

question

What is the size for oral airways? Colors?

answer

8- green 9- yellow, most often used 10-red

question

What are Mcgill forceps used for?

answer

-Nasal intubation

question

Epiglottis hangs down so which blade works better?

answer

Usually Miller blade, although Mac is easier to learn with. MAC- lifts vallecula but epiglottis hanging down (in & up motion) Miller- lifts up epiglottis tougher to see, tongue obstructs

question

ASA Classifications

answer

ASA 6: declared brain dead, organ donor ASA E: Emergency procedure, added to ASA I-VI Used for reimbursement/ report.

question

Most outpatient surgical centers will not operate on a patient above which ASA class?

answer

ASA 3

question

Narcotics

answer

Used for maintenance of general anesthesia "Balanced technique" -Most common fentanyl - Morphine, fentanyl, alfentanil, sufentanil, remifentanil

question

Dissociative Agents

answer

Ketamine (only anesthetic/analgesic combo) 2mg/kg -Dissociates patient from environment - Minimal depression of protective reflexes - Hallucinations are common on emergence

question

Muscle Relaxants

answer

-Defasciculating dose: depolarizer before succinylcholine to prevent muscle spasm/ soreness after surgery (5-10mg zemuron/rocuronium) - Succinylcholine, atracrurium, pancuronium, rocuronium, cisatracurium- (elimination PChE in blood)

question

Barbituates

answer

-Methohexital: ECT, dental, cardioversion, lowers seizure threshold 2mg/kg -Sodium Thiopental: 2.5% solution dose 4mg

question

Non-barbituates

answer

Propofol: Induction 1-3mg/kg

question

What is the MAC of halothane?

answer

MAC = .74 Hepatitis, slow acting, good for inhalation

question

What are some tricks you can use during long cases?

answer

8 hour case, anesthetics into fat, emergence on more expensive agent, maintenance on Iso, cheaper.

question

5 Questions in the following format

answer

Laparascopic appendectomy, (regional/general/IV sedation) anesthetic. This patient (will/will not/might) recieve paralytics. This patient will be in the (supine/prone/lateral/lithotomy) position. *If it is laparascopic the patient will require paralytic.

question

How can you tell when the case is nearing completion?

answer

Suture sizing: -small 10, big 0 - know progression of case Counting sponges/supplies towards the end of case.

question

How can you tell with propofol when you can intubate or bag?

answer

- Eyelash reflex -Listen with precordial stethoscope

question

Know brand/trade names of drugs

answer

Fentanyl: sublimaze Sufenta: sufentanil Alfenta: alentanil Demerol: meperidine Marcain: bubivipcaine: sensorcaine Lidocaine:xylocaine Remifentanil:ultiva Narcan:naloxone Rocuronium: zemuron Ravlon: rapacuronium (bronchospasms) Propofol: diprivan Versed: midazolam Edrophonium:reversol:enlon:tensilon Succinylcholine:anectine:quelicin Neostigmine: prostigmin

question

List local anesthetics short acting to long acting.

answer

Lidocaine>bubivicaine>tetracaine

question

Does epinephrine work well to prolong action of bubivicaine?

answer

Not really. Epi works well to prolong duration of lidocaine and tetracaine.

question

Advantages of Continuous Opioid Infusion Box12-4

answer

Hemodynamic stability Decreased side effects Reduced need for opioid-reversal agents Reduced need for vasopressor drugs Suppression of cortisol and vasopressin response to Cardiopulmonary bypass Reduced total dosage of opioids Decreased recovery time

question

The primary factors that influence absorption of the inhalation anesthetics are:

answer

Ventilation Uptake into the blood Cardiac output Solubility of the anesthetic drug in the blood Alveolar-to-venous blood partial-pressure difference (assumed to be the same as in the brain) Concentration Second gas effect

question

ASA Examples

answer

ASA 1: normal healthy patient ASA 2: smoker, OB, thyroid, HTN, mild health issue, DM, chronic bronchitis, anemia, morbid obesity, age extremes, heart disease-slightly limits activity ASA 3: COPD, CAD-limits activity, poorly controlled HTN, DM with vascular complications, angina pectoris, previous MI ASA 4: renal or hepatic failure, CHF, persistent angina, advanced pulmonary disease ASA 5: massive trauma , AAA, uncontrolled hemorrhage "Love to give scenarios and have you pick status"

question

Benefits of thorough chart review

answer

Identify surgical risks, anesthesia history, medical conditions etc.

question

Surgical History

answer

Chart or interview, particular attention paid to any complications mentioned by patient.

question

Anesthetic History

answer

Determine reaction of patient to previous anesthetics, can modify anesthesia approach to prevent recurrence of complication. Familial history: looking for atypical cholinesterase, MH, porphyria, glycogen storage diseases

question

Drug History: Prescription

answer

Provides excellent guide for direction and depth of patient interview and assessment. Alert provider to allergies or drug interactions.

question

Drug History: Herbal

answer

Echinacea: activate cell mediated immunity Ephedra: ↑ HR, BP Garlic: inhibits platelet aggregation, fibrinolysis, BP Ginko: inhibits platelet-activating factor Ginseng: ↓ BG, inhibits platelet aggregation increased PT-PTT Kava: sedation, anxiolysis St John's Wort: inhibits NT reuptake, MAO inhibition unlikely, interacts with several drugs Valerian: sedation Discontinuation: 24 hours: ephedra, kava 36 hours: ginko 5 days: St. John's 7 days: garlic and ginseng

question

Tobacco

answer

Nicotine produces ganglionic stimulation, affects CV system. INCREASE: ↑HR, ↑BP, ↑contraction, ↑oxygen consumption, ↑PVR Carbon monoxide binds to oxygen binding sites on hemoglobin causing hypoxia. 12 hour cessation prior to surgery will decrease pulmonary complications and improve outcome.

question

ETOH

answer

Cut down alcohol use? Annoyed by people criticizing your habits? Guilty about drinking? Eye opener in the morning? More than 2 yes responses at risk for alcoholism. Signs of withdrawal: hand tremors, sweating, tachycardia, systolic HTN, anxiety, restlessness, N/V, hallucination, seizure Patient may show a resistance to other CNS depressants.

question

Illicit Drug Abuse

answer

Most abused are cocaine & marijuana. Signs & Symptoms: track marks, pupillary dilation or nystagmus, lymphadenopathy, malnourishment, poor dental care, nose perforations

question

Informed Consent

answer

Give reasonable explanation of available options for anesthesia: general, regional, local, topical or IV. Written consent recommended for medicolegal purposes. Ensure sufficient information is given about the procedures and risks that a reasonable and prudent decision can be made.

question

ECG

answer

Baseline >50 years Indications: CV disease risk Pathological murmur or palpitation Prolonged QT syndrome Moderate to severe sleep apnea (R sided strain)

question

CXR

answer

Risk usually outweighs benefit in healthy <75 year patients. Indications: abnormal CXR in past TB/ +skin test w/ no tx pulmonary infection (cough, abn.sputum) congenital heart disease, premature dysp. sleep apnea down syndrome (sublaxed atlantoaxial) malignancy that alters surgical care-mets sym/debil. COPD, asthma, Cardiovasc.

question

Pregnancy Test

answer

Routine pre-op test remains controversial. Advise of fetal risk (spont. abortion) surgery advised after 1st trimester Interview by female staff w/o family

question

Lab Draws

answer

Considered current if within 6 months and no change in patient condition. Serum potassium should be within 7 days if diuretics or digitalis is planned. BG on day of surgery. ECG within 30 days with stable disease. Chest X-ray 6 months if stable disease.

question

Fasting Considerations

answer

>6 hours for solids 4 hours breastmilk 2-3 hours for liquids no gum/ candy after midnight meds with sip 150ml-adults, 75ml-kids up to 1 hr anesthesia

question

Airway: Prediction of a Difficult Airway

answer

Mallampati: Easy in class 1-2, difficult 3-4 Thyromental distance: prominence of thyroid cartilage to bony point of mandible, <7 difficult intubation Interincisor distance: <4cm open, difficult intubation Head & neck movement: "sniff position" less tongue obscures view, inability to move neck, difficult intubation Mandibular mobility: bite upper lip, move jaw forward, easy maneuvering of laryngoscope

question

Musculoskeletal/ Obesity

answer

2/3 of US adults overweight or obese Greater risk of CV and airway issues.

question

Neurological

answer

Musculoskeletal system, sensory system, muscle reflexes, cranial nerve abnormalities, mental status & speech pattern. ECG: Q waves, deep inverted T waves, ST elevations may reflect hypothalamic ischemia & sympathetic overactivity (SAH)

question

Cardiovascular

answer

HTN is most common circulatory issue, risk factor for CAD, increases perioperative mortality. Unstable angina associated with the highest risk for perioperative MI. Patients are most at risk if MI in last 30 days. S & S: tachycardia at rest, moist rales in lungs, S3, peripheral edema *CAD main cause of death.

question

Respiratory

answer

Some form of lung disease present in 25% of adult population. The surgical site (aortic & thoracic surgeries) most important risk factor for development of post-op pulmonary complications. Most common: COPD, asthma, chronic bronchitis, emphysema

question

Gastrointestinal

answer

Assess: N/V/D, GI bleed, masses, dysphagia, acidity, abd/ referred pain, gastric hyperreactivity, weight loss, malnutrion Prophylactic measures in at risk patients ( EG: bicitrate to decrease stomach pH in case of aspiration)

question

Hepatobiliary

answer

Acute or chronic liver disease. Unexplained jaundice or ↑ transaminase levels should be evaluated by gastroenterologist. (post-pone surgery) Lactate dehydranase (LDH) more specific Prolonged PTT offers most rapid & reliable hallmark of liver dysfunction with acute injury.

question

Renal

answer

Evaluate fluid status, infection, retention/incontinence, hematuria Clinical signs may not be evident until >70% of nephrons are non-functional. Creatinine levels correlate more with GFR than BUN. Renal reserves: creatine clearance rate Mild renal dysfunction: < 50-80 ml/min Renal failure: <10 ml/min Monitor K 6-8 hours pre-op, HGB due to chronic anemia

question

Endocrine: Diabetes

answer

Diabetes is most common, 20.8 million people in US. DM: hyperglycemia & ketoacidosis Death is usually secondary to complications from artherosclerosis. High risk of ischemic heart disease: 12 lead EKG ↓ gastric emptying time, give reglan to reduce incidence of aspiration Goal of perioperative insulin therapy is 60

question

ASA Status Classification

answer

...

question

Guidelines for Preventing OR Errors

answer

Preoperative Verification Process Mark Operative Site Time-out immediately before procedure: Correct ID Correct side & site Agreement on procedure Correct patient position Availability of correct equipment

question

Valvular Heart Disease

answer

Aortic & mitral valve lesions most common. Severe aortic stenosis is greatest risk especially if cross section of aorta is < 1 cm

question

Arrythmia

answer

Dyspnea, angina or syncope suggests worsening disease. Ventricular Arrythmia Categories: 1- benign: unifocal PVC 2- potentially malignant: organic heart disease, on anti-arrythmics 3- malignant: organic heart disease, hemodynamic compromise, familial history of sudden cardiac death

question

Pacemakers

answer

Can mask the toxicity of anti-arrythmic drugs, electrolyte disorders, and myocardial ischemia & irritability

question

Diagnostic Testing for CV Disease

answer

Significant coronary disease likely if ST depression > .2 mV or if hypotension occurs. Significant stenosis: >70% narrowing of major coronary artery >50% of L main coronary artery

question

Emphysema & Chronic Bronchitis

answer

ABG: PaO2 < 60= chronic bronchitis FEV/FVC <80%= obstructive process

question

Asthma

answer

Reversible airflow obstruction, inflammation of airways. Assess frequency, severity & triggers of attacks.

question

Children & Upper Respiratory Tract Infection

answer

S/S: inflamed reddened mucosa, mucus, fever Postpone if possible, <5 years old= ↑ risk Intubation ↑ risk 11 fold

question

Mallampati

answer

...

question

Hyperthyroidism

answer

Excess T3 & T4 Hypermetabolic state, sympathetic overactivity. Use esmolol intraop and continue patients meds

question

length of upper incisors cautionary finding

answer

relatively long

question

relation of maxillary and mandibular incisors during normal jaw closure cautionary finding

answer

overbite (maxillary anterior to mandibular)

question

relation of maxillary and mandibular incisors during voluntary protrusion of jaw cautionary finding

answer

mandibular incisors anterior to maxillary incisors

question

Interincisor distance cautionary finding

answer

<3 cm (2 fingers)

question

visibility of uvula cautionary finding

answer

not visible when tongue is protruded in sitting position (Mallampati > II)

question

shape of palate cautionary finding

answer

highly arched or very narrow

question

compliance of mandibular space cautionary finding

answer

stiff, indurated, occupied by mass, not resilient

question

thyromental distance cautionary finding

answer

less than 3 finger-breadths (7cm)

question

length of neck cautionary finding

answer

short

question

thickness of neck cautionary finding

answer

thick

question

range of motion of head and neck cautionary finding

answer

patient cannot touch tip of chin to chest or cannot extend neck

question

most common anesthesia related medicolegal claims?

answer

dental injuries (inspect teeth and document missing, fractured, crowns, braces, ect.) inform patient of liklihood of dental damage and document on consent form to not be held liable

question

obesity

answer

20% in excess of ideal body weight

question

Ideal Body Weight calculation

answer

Men- 105lb + 6lbs for each inch > 5ft Women 100lb + 5lbs for each inch >5ft

question

Body Mass Index

answer

BMI= Weight in kg / height in meters²

question

Overweight BMI

answer

25-29.9kg/m²

question

moderate obesity

answer

30-34.9kg/m²

question

severe obesity

answer

35-39.9kg/m²

question

morbidly obese

answer

>40kg/m²

question

Asymptomatic patients should be screened for CAD if:

answer

1. abnormal baseline ECG 2. Hx of CAD/ valvular disease 3. 50 yr old and at least two: metabolic syndrome, DM, HTN, smoker, dyslipidemia, fam hx CAD

question

order pre-op sleep study if:

answer

H & P suggest obstructive sleep apnea snoring, apneic, freq. arousal during sleep, am HA, daytime sleepiness

question

anticipate difficult intubation

answer

awake intubation fiberoptic tracheal intubation drying agent upper airway anesthesia

question

Pre-op carotid endarterectomy

answer

cardiac eval by cardiologist 12- Lead ECG stress testing (at risk for MI)

question

patient with vertebral artery occlusion

answer

avoid extreme head extension, flexion, and rotation

question

Intracranial HTN avoid:

answer

sedatives, ketamine, desfluare

question

Patient is taking Phenytoin, Pre-op labs:

answer

CBC (risk for agranulocytosis) check drug level to see if therapeutic (check level with all anticonvulsants if able)

question

Signs of Cardiovascular Disease

answer

dyspnea, chest pain, fatigue, syncope, palpitation, angina obtain 12-Lead EKG

question

uncontrolled stage 3 HTN

answer

>180/110 delay surgery if organ damage is suspected heart, renal, cerebrovascular disease and condition could be improved by postponement to extent risk would be considerably decreased or care may be influenced by further pre-op exam

question

patient complains of dizziness/ syncope

answer

investigate may be cerebrovascular insufficiency or drug induced hypotension

question

Cardiovascular Physical Exam

answer

overall appearance vital signs funduscopic exam neck heart lungs abdomen extremities neuro eval

question

unstable angina elective surgery

answer

cancel until cardiovascular status can be evaluated and optimized p377

question

patient with dyspnea of unknown origin or with heart failure should undergo:

answer

pre-op eval of left ventricular function if not performed in last 12 months p.378 angiography, echocardiography, contrast ventriculography EF < 35%

question

severe aortic stenosis patient

answer

14- fold greater incidence of peri-op sudden death delay elective surgery if patient symptomatic

question

hx of symptomatic arrhythmias pre-op

answer

ECG K+/ Mag levels test level of antirhythmic drug if possible chest x-ray (if structural heart problem)

question

pacemakers can mask s/s of:

answer

MI, electrolyte abnormalities, toxicity of antirhythmic drugs, irritability

question

what function of a pacemaker is lost first

answer

sensing

question

consult cardiology for pacemaker if:

answer

pacing impulse if not associated with pulse unexpected pauses symptoms pre pacemaker have returned

question

indication for temp, transvenous pacer wire pre-op

answer

persistent bradycardia unresponsive to IV atropine/ exercise Bifascicular block with syncope hx suggesting complete heart block

question

dizziness caused by exercising the muscles adjacent to the pacemaker implies:

answer

myopotentials may be inhibiting pacemaker avoid shivering and succs which cause muscle fasciculations

question

Stress Test demonstrates

answer

how ischemia manifests itself functional hx of angina extremes of BP/HR tolerated location of ischemic leads present of arrhythmias

question

ECG s/s of significant coronary disease

answer

ST-segment depression >0.2mV ST depression early in stress test little increase in BP/HR occurs w/ ST depression hypotension occurs with ST depression (hypo prompt cardiac cath)

question

significant stenosis means

answer

narrowing of major coronary artery by 70% or narrowing of left main coronary by 50%

question

findings of poor ventricular function

answer

CI 18 mm Hg EF < 40%

question

pulmonary s/s that indicate elective surgery should be postponed

answer

severe dyspnea wheezing pulmonary congestion hypercarbia CO2>50

question

ABG Values indicating chronic bronchitis

answer

PaO2 < 60mm Hg with or w/o CO2 retention likely to develop cor pulmonale

question

Chest X-ray finding indicating COPD (emphysema)

answer

emphysema bullae pulmonary hyperlucency (vascular deficiencies in the lung periphery) Diaphragmatic flattening vertical cardiac silhouette

question

pulmonary function test

answer

determine severity of airflow obstruction and reversibility with bronchodilators FEV1/FVC less than 80% indicate obstructive process poor indicator of post-op pulm complication reserved for symptomatic pts with COPD prior to non-cardiothoracic surgery "<60% bad, FEV₁ <40% likely ventilated, <30% ventilated"

question

all patients undergoing lung resection should have what assessment pre-op

answer

spirometric assessment estimates FEV1 and suitability for resection

question

asthma

answer

reversible airway flow obstruction inflammation of the airways distal bronchoconstriction from airway hyperreactivity to stimuli

question

s/s of asthma indicating postponement of elective surgery

answer

wheezing, tachypnea, persistent cough

question

Patients at risk for per-op asthma aggravation

answer

co-existing cardiovascular disease recent hospitalization/ ER visit for asthma hx of peri-op asthma complications copious sputum production nocturnal awakening from asthma freq/cont corticosteroids

question

pre op therapy to decrease pulmonary complications

answer

stop smoking psychological preparation antibiotics for pulm infection/ bronchitis weight reduction chest PT expectorants instruction in resp maneuvers brochodilator for asthma good nutrition

question

post op therapy to decrease pulmonary complications

answer

pain control (avoid opiates) hydration IS, maximal inspiration maneuvers Chest PT mobilize secretions cough ambulation heparin (selected cases)

question

Medical History of Asthma

answer

frequency, time since last attack, last hospitalization, corticosteriod use, β-agonist use Don't want to give beta blocker- negate effect of albuterol

question

if right ventricular hypertrophy is presumed

answer

ECG implies long standing insufficient pulmonary therapy

question

when to get a chest x-ray pre op for lung issues

answer

suspect acute infiltration process like PNA or pneumothorax

question

when to get an ABG pre op for asthmatic

answer

signs of hypoxia/ hypercarbia who required emergency surgery

question

Peak Expiratory Flow Rate morning of surgery with active asthma disease

answer

compare with patient's best in recent weeks normal:80-100% moderate exacerbation: 50-80% of baseline severe episode indicating delay of surgery and more intensive therapy: <50%

question

Asthma pre-op meds

answer

β-adrenergic inhaler morning of surgery and bring to OR oral meds with sip of water 1-2 hrs preop therapeutic theophylline levels confirmed 10-20mcg/mL supplemental stress dose of corticosteroids anti-anxiety med adequate hydration

question

s/s of lower resp tract infection

answer

fever >38 pulmonary congestion rales

question

Upper Resp Tract infection- cancel surgery?

answer

uncomplicated URTI okay for elective surgery and no intubation esp if chronically has colds/ runny nose/ afebrile/ no distress CANCEL if: productive cough from lower RTI, infectious runny nose, less than 1, caution with <5, infectious nasopharyngitis: 2weeks postponement " " with Lower RTI: 4-6 weeks " "

question

Asthma Pharm Pre-op Tx for Patient on brochodilators

answer

inhaled corticosteriods, beclomethasone 320mcg per day, 1 week pre-op

question

Asthma Pharm Pre-op Tx for Patient with spirometry at or below baseline/ flare-up of symptoms

answer

predisone 0.5mg/kg for 5 days pre-op hydrocortisone 100mg IV q8hrs the morning before surgery and postop until stable

question

Asthma Pharm Pre-op Tx for Patient on Oral Steriods

answer

Increase dose for 5 days hydrocortisone 100mg IV q8hrs the morning before surgery and postop until stable

question

Cancel elective surgery for hepatic failure with what s/s

answer

grossly abnormal liver function test including coagulopathies extreme jaundice cyanosis gen tremors increased deep tendon reflexes ascites, spider nevi, hepatospenomegaly hepatorenal failure hepatic encephalopathy

question

Intra-op care of hepatic failure

answer

phytonadoine (AquaMEPHYTON) FFP/ cryoprecipitate for abnormal coags no pre-op sedative for hepatic encephal. check blood sugar ABG, CMPs, LFT

question

alkaline phosphatase enzyme

answer

may be released from bile duct in biliary obstruction/ irritation and help differentiate disease (but also from extrahepatic tissues as well) high conjugated bilirubin helps confirm cholestatic liver disease

question

hepatotoxic drugs

answer

acetaminophen NSAIDs ASA methydopa isoniazid rifampin

question

Tx and resolution of UTI esp before surgeries:

answer

prosthetic graft for mitral valve total hip replacement

question

would you expect creatinine levels to be high or low in elderly?

answer

normal even though decrease GFR, have lost of muscle mass which lowers number

question

GFR/ Creatinine Clearance

answer

UV (urinary concentration of creatinine X volume of urine) / P ( plasma concentration of creatinine)

question

Pre-op Potassium for Renal Patients obtained when

answer

6-8hrs pre- surgery regardless if dialysis or not

question

Delay elective surgery until after dialysis

answer

Potassium 5.5 and CHF is apparent

question

extreme fatigue, pallor, limited exercise tolerance, tachycardia pre-op tx

answer

RBC tranfusion

question

Cause of anemia Cause of coagulopathies in Renal Failure

answer

Anemia- Erythopoietin, fragile RBCs Coags- decreased platelet adhension bc chronic metabolic acidosis Hemodialysis can correct prolonged bleeding time

question

Pre-op Meds for Chronic Renal Failure Patient

answer

continue antihypertensive, digitalis, corticosteriods, and insulin less pre-op sedation, avoid valium GI antiacids, gastrokinetic agents (Reglan) drain peritoneal dialysate (reduce asp.)

question

Type I DM prone to what diseases

answer

organ failure diabetic retinopathy cataracts somatic/ autonomic sufficiency ( ortho hypotension, bradycardia, gastoparesis) ketoacidosis hyperglycemia

question

Extreme Hyperglycemia and Ketoacidosis Pre-op

answer

Cancel elective surgery Fluids, electrolyte, and insulin therapy

question

Consult Cardiologist for DM patient if:

answer

risk of MI- carotid endarterectomy/ ab aortic aneurysm r/sx consider: stress test, 12-Lead ECG

question

s/s of autonomic neuropathy

answer

orthostatic hypotension resting tachycardia lack of respiratory variability in cardiac rhythm

question

Diabetic Pre-op Meds

answer

Hold oral short half-life agents on day of surgery: Thiazolidinediones: "-glitazone", Glinides: Repaglinide, Alpha-glucosidase inhibitors: Acarbose, Miglitol Withhold longer-acting 48hrs: Biguanides: Metformin Sulfonylureas: "-amide," "-rides," "-zides"

question

Insulin pre-op for DM 1

answer

SubQ 1/3 to 1/2 of patient's morning dose of intermediate or long acting insulin

question

pre-op med for hyperthyroid

answer

anti-thyroid drugs: methimazole or propylthiouracil for 6-8 weeks followed by iodine for 7-14 days CBC pre-op (pro. causes agranulocytosis) Beta-antagonist: Propanolol, Esmolol

question

postpone elective surgery for hyperthyroid patients until

answer

euthyroid

question

Emergency surgery for hyperthyroid

answer

Esmolol 100-300mcg/kg/min Higher doses of Benzos, Anxiolytics, sedatives avoid anticholinergics

question

Hypothyroid Meds Pre-op

answer

Levothyroxine, IV fluids, electrolytes

question

Should you delay surgery for mild/ moderate hypothyroidism

answer

No

question

Cushings syndrome

answer

excess glucocorticoids hypertension HYPOvolemia easy bruising osteoporosis

question

Hyperaldosteronism

answer

excess mineralcorticoid hypertension hypokalemia <3 sodium and water retention metabolic alkalosis

question

Addison disease

answer

glucocorticoids and often mineralocorticoids insufficiency inhibition from steroid therapy weight loss, skin hyperpigmentation, muscle wasting HYPOtension HYPOvolemia HYPOglycemia HYPOnatremia HYPERkalemia

question

Adrenocortical Dysfunction Pre-op Treatment

answer

Correct Fluid & Electrolytes, Tx Coexisting disorders (HTN, DM) Replace mineral/glucocorticoids Corticosteriods for pt tx with steriods for more than 1mo in past year and supplement daily dose if currently taking

question

Pre-op Dx Test Considerations

answer

cost-effective-cost saved from knowing results exceed expense of performing it positive benefit-risk ratio- benefits outweighs harm from false-positive available pre-surgery for intervention yield info no attainable from H&P Abnormal results in asymptomatic pt would influence care, surgery, anesthesia

question

False-positive and false- negative test results lead to....

answer

additional medical eval and potential for increased MORBIDITY 5% abnormal in normal pt if abnormal not investigated =medicolegal risk

question

Patients at Risk for Cardiovascular Disease

answer

DM >40, cocaine, HTN, renal failure, circulatory disease, thyroid disease, pulmonary disease, ischemic heart disease, heart failure, cerebrovascular d

question

Preform pregnancy test if..

answer

patient is uncertain of status sexually active info last menstrual period indicates possibility birth control present/absent policies of hospital protocol mandate

question

Indications for CBC

answer

hematologic d/o vascular procedure chemotherapy unknown sickle cell status

question

Indications for HCT & HGB

answer

Age < 6mo (<1 yr if premature) hematologic malignancy radiation/ chemo renal disease anticoagulant therapy mod/high blood loss potential systemic d/o (cystic fibrosis, premature, malnutrition, renal, liver, congenital heart disease)

question

Indications for WBC Count

answer

Leukemia/ Lymphomas Radiation/ Chemo suspect infection that would cancel surgery aplastic anemia (bone marrow ↓) hypersplenism autoimmune collagen vascular disease

question

Indications for Blood Glucose

answer

DM Corticosteriods hx of hypoglycemia adrenal disease cystic fibrosis

question

Indications for Serum chemistry

answer

Renal Adrenal (K/Na) Thyroid Disease (↑ Ca w/ hyper) Chemo Pituitary (DI-Na) Hypothalamic Body Fluid Loss/Shift-dehydration/bowel Central nervous system disease

question

Indications for Potassium

answer

Digoxin therapy Diuretic therapy

question

Indications for Creatinine and Blood Urea

answer

Renal Nitrogen Cardiovascular disease (HTN) Adrenal DM Diuretic Digoxin Blood Fluid Loss or shift- dehy/bowel Radiocontrast procedure

question

Indications for Liver Function Test

answer

Hepatic disease Exposure to hepatitis Therapy with hepatotoxic agents

question

INR, Prothrombin, Partial Thromboplastin Time

answer

Leukemia Hepatic disease Bleeding disorder Anticoagulant therapy severe malnutrition/ malabsorption

question

Indications for Platelet Count/ Bleeding Time

answer

Bleeding Disorder Abnormal hemorrhage, purpura, history of easy bruising

question

Indications for Urinalysis

answer

not indicated as routine screening

question

Indications for Medication Levels

answer

Theophylline, Phenytoin, Digoxin, Carbamazepine if pt exhibits s/s of ineffective therapy, potential drug s/e, or poor drug compliance, or changed therapy w/o documented level

question

Does ASA classification system represent an estimate of anesthesia risk?

answer

No, rough correlation between physical status and post-op outcome, but does not account for other factors:surgical procedure, degree of peri-op monitoring, unfortunate circumstances (human error and equipment malfunction)

question

Guideline for Implementing Universal Protocol for preventing Wrong Site, Procedure, Person

answer

Preop Verification Process Marking the Operative Site Time-Out Immediately Before Starting Procedure

question

Universal Protocol Preop Verification Process When:

answer

surgery/procedure scheduled admission or entry in the facility anytime care is transferred to another provider with the patient involved, awake, aware before patient leaves preop area or enters surgical/procedure room

question

Preop Verification Checklist

answer

Relevant documentation (H & P, consent) Relevant images, labeled, displayed Any required implants, special equipment

question

Marking the OP Site

answer

At/ near incision Initials or "YES" (don't use an x) visible after pt prepped/ draped permanent marker (adhesive markers need 2nd marker) Method consistent throughout hospital Mark when involves laterality, multiple structures, multiple levels patient involved, awake, aware final verification during time-out defined procedure if pt refuses marking

question

Exemptions to Marking Site

answer

single-organ case catheter or instrument insertion site not predetermined (cardiac cath) teeth- but indicate op tooth on documentation or mark op tooth on dental radiographs or dental diagram premature infants (b/cm tattoo)

question

Time-Out Immediately Before Starting Procedure

answer

involves entire operative team in procedure location active communication documented Includes: Correct patient ID Correct Side and Site Agreement on Procedure to be done Correct Patient Position Available Correct Implants, special equip

question

Procedure for Non-Operating Room (ex:Bedside) Time-Out

answer

Site marking for laterality, multiple structures, multiple levels Verification, site-marking, time-out consistent throughout hospital Exception of site marking: case in which individual doing procedure is present and with patient from time decision made to do it to execution (still do time-out)

question

when should patients with a complex medical condition be evaluated?

answer

at least 1 week before scheduled surgery

question

Med Conditions that would benefit from early Pre-op Evaluation p.359

answer

inhibit normal daily activity, require monitoring/ cont. assistance at home w/i 6 months Hospital Admission for exacerbation in 2 months Meds that need modification of schedule/dosage Angina, CAD, MI, symptomatic arrhythmia, HTN > 160/110, CHF Asthma & COPD w/ chronic meds/exacerbation 6mo Hx of airway surgery, trauma, unusual anatomy, tumor Home ventilation/ monitoring DM treated with insulin/ oral hypoglycemic agents Adrenal d/o, thyroid disease hepatobiliary disease kyphosis, scoliosis, TMJ w/ restricted mobility cervical/ thoracic spine injury chemotherapy/ compromise oncologic pt Morbid obesity > 140%, hital hernia, symptomatic GERD

question

Chart Review includes

answer

Past Med Hx: previous anesthesia records/ unusual condition Patient Chart Review: verify consent with name, surgeon, procedure, date- demographics-vitals - I/O- baseline deficits- preanesthesia questionnaire

question

T/F It is acceptable to review diagnostic tests from the chart?

answer

False, must be obtained directly from original source

question

T/F It is acceptable to review medical treatment, drug dosages, and schedules from the chart?

answer

True

question

when should a patient bè tested for latex allergy?

answer

family history report of rash, swelling, or wheezing when exposed

question

when would you expect a latex allergy?

answer

chronic exposure to latex-based products spina bifida, urological reconstruction more than 9 surgeries intolèrance to latex-based products allergy to food and tropical fruits intraop ànaphlaxis of unknown cause health care worker esp w/ atopy/eczema

question

common post op complications of smokers

answer

purulent sputum, bronchospasm, secretion retention, pleural effusion, pneumothorax, pulmonary collapse, pneumonia

question

periop complications of children exposed to second-hand smoke

answer

larynospasm, coughing on induction/emergence, breath holding, post op oxyhemoglobin desat, reactive diseàse, abnormal PFTs, RTI

question

Periop complications of alcoholics? post- op complications?

answer

arrhythmias, infection, withdrawal syndrome post: poor wound healing, infection, bleeding, futher hepatic deterioation

question

abstinence syndrome s/s ( from illicit drugs)

answer

increased sym and parasympathetic HTN, tachycardia, abd cramping and diarrhea, tremors, anxiety, irritability, lacrimation, mydriasis, algid sweat, yawning

question

s/s of long term androgen use (steriods)

answer

↓ liver, hepatic adenocarcinoma, peliosis, hepatisis, MI, atherosclèrosis, hypercoagulopathy, stroke, HTN, dyslipidemia, pstchiatric/ behavior abnormal

question

anesthesia implication for chronic steriod abuser

answer

liver functioning test to determine potential hepatotoxicity with drugs given thát are metabolized by the liver

question

cannabis abuse s/s

answer

tachycardia, headache, labile BP, euphoria, dysphoria, depression, anxiety, panic reactions, psychosis, poor memory, decreased motivation

question

cocaine & amphetamine abuse s/s

answer

↑HR, labile BP, HTN, MI, arrhythmias, pulmonary edema excitement, delirium, hallucinations-psychosis euphoria, feeling of enhanced physical and mental capacity hyperreflexia, tremors, convulsions, mydriasis, sweating, hyperpyrexia, exhaustion, coma

question

hallucinogens abuse s/s (LSD, PCP)

answer

sympathomimetic, weak analgesics altered perception/ judgement- toxic psychosis dissociative anesthesia

question

opioid abuse s/s

answer

resp depression, hypotension, ↓HR, constipation, euphoria, pinpoint pupils, decreased LOC, coma

question

What is the difference between a MAC and a general?

answer

MAC: no tube GA: usually tubed

question

What is an albumin level used for?

answer

Nutritional status and protein binding of drugs.

question

What is adjusted body weight used for and how is it calculated?

answer

IBW + (real body weight - IBW)/3

question

What can you use for patient's with veneers?

answer

*1/3 of all anesthesia claims are based on dental issues. Use dental guard to protect.

question

NPO guidelines

answer

Food, milk :6 Breast Milk: 4 Clear liquid: 2 * When in a trauma situation, count NPO status from the time of injury.

question

Mallampati once more...

answer

MP /Lip bite I - all structures uvula tip, soft palate, fauces, pillars II - no pillars III - no fauces IV - hard palate only Lip bite study "more sensitive indicator"

question

Mitral Stenosis

answer

- HR: keep slow to allow for filling, avoid sinus tachycardia - Rhythm: sinus, a-fib (control rate) -Preload: maintain or slightly increase to help with left ventricular filling, excess preload -Afterload: SVR maintain, avoid decreases in SVR -Contractility: maintain to provide adequate cardiac output *Epidural preferred over spinal.

question

Mitral Stenosis

answer

-Reduced LV preload - Avoid tachycardia - Full intravascular volume (normovolemia) -Avoid pulmonary HTN: hypoxia, hypercarbia, nitrous - New onset a-fib: flutter requires immediate cardioversion *NTG, milrinone, nitric oxide are pulmonary vasodilators Decrease HR beta block Epidural over SAB

question

Mitral Regurgitation

answer

-HR: maintain or ↑, avoid bradycardia which worsens regurgitation - Rhythm: sinus rhythm - Preload: maintain or ↑ (elevated= ↑ regurg/ low= inadequate CO - Contractility: maintain or ↑ to decrease LV volume

question

Aortic Stenosis

answer

- Maintain SR - Maintain normal intravascular volume - Avoid ↑ HR - Avoid hypotension - Arterial PA catheter and TEE monitoring very helpful - Early and aggressive treatment of hypotension and arrythmias is imperative 14 fold increase in peroperative death Degree mild mod severe? SAB: hypotension tachy not tolerated Treat hypotension aggressively no ephedrine, use neo Epidural slowly comes on instead of bolus

question

Aortic Insufficiency

answer

- Decrease SVR - Optimize intravascular volume - With preserved LV function, dilation, and tachycardia - Avoid bradycardia as it causes ventricular distention - PCWP underestimates true LVEDP in acute aortic insufficiency because of premature closure of MV -Antibiotics

question

Should beta blockers, cardiac meds be continued the day of surgery?

answer

Yes

question

When should ACE inhibitors be held?

answer

Day of, hypovolemia, BP can bottom out

question

When should MAOI be held?

answer

Hold for 2 weeks Ensure psych eval or provider aware during hold

question

TCA held?

answer

2 weeks

question

Lithium held?

answer

72 hours

question

Diuretics

answer

Hold, check chem profile

question

Insulin

answer

Regular: hold day of Long acting: 1/2 dose

question

Warfarin, heparin

answer

Warfarin: Hold for 5 days, may bridge with heparin Heparin: 6 hours

question

Steroids

answer

Give stress dose

question

METS Metabolic Equivalent Measures

answer

How well can this patient handle exertion. 1 flight of stairs without getting winded >4, can't <4 Putting patients under cardiac stress

question

EKG indications

answer

Male >50 Female > 60 Subtract 10 years to maximum of 20 years for each comorbitity.

question

LBBB

answer

LBBB V1= broad S, V6 = broad R

question

RBBB

answer

RBBB V1= rSR, V6= broad S

question

R wave progression

answer

R wave progression: flips positive to negative in leads V3-4 Poor (late)= ant MI, LBBB, WPW, L vent hypertrophy

question

What is the Bain-Bridge reflex?

answer

Breathing pushes diaphragm down and vena cava opens up, ECG moves in a wave with respiration due to lead placement or they are hypovolemic.

question

Electrolyte Abnormality and ECG

answer

Hyper Ca+ shortens ST monitor these intra op Hypo Ca+ prolong QT blood transfusion will cause (raises K) Hyper K+ peak T waves Hypo K+ u wave inside of T wave

question

5-H-T-3

answer

Antiemetics prolong QT interval

question

Unstable Angina

answer

(1) CP w/ rest or unresponsive to meds, or >30 min duration (2) Non Q wave, non troponin, non CKMB (3) cardiac w/u and even then keep HR low normal and BP normal *Sleeping at night and wakes them up, watching TV

question

MI Mortality

answer

Peri-operative mortality > 6mos: 6% 3-6 mos: 30% < 3 mos: 50% < 30 days: do not do it unless case of life or death AHA says wait 4-6 weeks min *Q wave will indicate previous MI

question

Pacer/ Magnet

answer

-Chamber paced A,V D -Chamber sensed A,V D -Rate responsive inhibition (I), triggered (T), none(O Magnet for AICDs usually deactivates (not always) Pacer wires may dislodge New do not lift arm Dizziness w/ arm motion exercise Monitor 5 lead intraop for all serious CV conditions *Electrocautery will throw off AICD or pacer. Tech can interrogate and ID underlying rhythm. Avoid succinycholine, fasciculation....

question

How long post cessation of smoking does carboxyhemoglobin return to normal?

answer

12 hours, also ↓ HR and BP *Want them to stop >8 weeks or about 12 hours. Use sevo, less irritation, give nebulizer.

question

PFT

answer

PFT <60% bad lung function FEV1<40%, post op ventilated likely FEV1<30% for sure post op ventilated

question

Neurological

answer

Versed for seizure, continues paralyze and intubate Avoid opioids, ketamine, succinylcholine, RSI with rocuronium, brevital Which agent has least increase in ICP? Sevo or Iso (no Des)

question

LMA contraindications

answer

Intubate for case longer than 2 hours. TURP: lithotomy, ↑ gastric pressure, avoid LMA

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